Year : 2015 | Volume
: 141 | Issue : 2 | Page : 255--256
TIA as acute cerebrovascular syndrome
MV Padma Srivastava
Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi 110 029, India
M V Padma Srivastava
Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi 110 029
|How to cite this article:|
Padma Srivastava M V. TIA as acute cerebrovascular syndrome.Indian J Med Res 2015;141:255-256
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Padma Srivastava M V. TIA as acute cerebrovascular syndrome. Indian J Med Res [serial online] 2015 [cited 2020 Jan 22 ];141:255-256
Available from: http://www.ijmr.org.in/text.asp?2015/141/2/255/155604
TIA as acute cerebrovascular syndrome, S. Uchiyama, P. Amarenco, K. Minematsu, K.S. L.Wong, editors (Karger, Basel, Switzerland) 2014. 166 pages. Price: US $ 209.00 / CHF 178.00
Acute cerebrovascular syndrome (ACVS) encompasses both transient ischaemic attacks (TIAs) and acute ischaemic stroke (AIS), akin to the concept of acute coronary syndrome (ACS) which includes both unstable angina and acute myocardial infarction. This book showcases this concept in great detail and with evidence. TIA is generally not accorded the same kind of importance or adequacy of response or evaluation on account of the "transiency" of the clinical features and "normal" patient on examination. This is most unfortunate as TIA singularly is one of the most powerful "warning" features for patients and clinicians to avert the impending stroke which can be a major disaster.
Chapter 1 presents the saga on TIAs with a scintillating journey through the historical aspects of the nomenclature and evolving definitions of the term TIA. The second chapter describes in detail the novel and emerging concept of ACVS. Based on data from international registries and analysis of data from patients with TIA who underwent radiological investigations, it has been observed that TIA and AIS are on the same spectrum of acute ischaemic syndrome in the central nervous system (CNS). Unlike ACS, the mechanism of ACVS is complex and protean and there are no measurable biomarkers for ACVS unlike ACS. Thus, the identification and management of ACVS become more complicated than ACS. There is also emphasis on the dynamic nature of the neuroimaging findings in TIA. Distribution of the findings is continuous and magnetic resonance imaging (MRI) positivity is influenced by the timings of imaging. MRI positivity should be used as a high risk marker for subsequent stroke and not for differentiation of TIA from AIS.
The next chapter is on TIA as a medical emergency. On account of the multiple mechanisms leading to TIA, the prompt subtyping of ischaemic stroke using standard protocols and multifaceted prophylactic interventions are mandatory to prevent subsequent stroke. To prevent subsequent stroke arising from TIA, antiplatelet and anticoagulant therapies should be started immediately along with comprehensive management of lifestyle, vascular risk factor control and when indicated, carotid endarterectomy (CEA) or carotid angioplasty stenting (CAS) for significant stenosis of ICA.
The concept of TIA clinics, their relevance in stroke prevention has been discussed in the fourth chapter. The high risk of imminent stroke following TIA can be decreased by nearly 80 per cent, if patients are immediately triaged, investigated and managed by stroke specialists after TIA. This sense of urgency when a patient has already improved and presents with no deficit, needs to be inculcated, instilled and ingrained amongst both the public and the first contact physicians in medical practice. Management of these patients in emergency requires well-organized dedicated health care systems such as TIA clinics. This approach has already proven to be safe and cost-effective avoiding full hospitalization in most cases.
The next chapter discusses the risk scoring for TIA. Earlier scores such as ABCD2 and newer modifications and refinements such as ABCD3I, ASPIRE, ABCDEF have been described. The main refinements in these scoring systems were to include imaging results such as DWI positivity or aetiologic considerations such as carotid artery stenosis or atrial fibrillation. Since these new scores necessitate an extensive diagnostic workup, these would be feasible in only large comprehensive stroke centres. Universally, across different clinical practice settings, it is ABCD 2 score which is the simplest and recommended in several guidelines.
Chapter 5 gives a comprehensive picture on the epidemiology of TIA. What is available so far in published literature has been succinctly presented. The need for further clarity on various epidemiological aspects of TIA has also been expounded.
The clinical features of presentation, recognition and diagnosis have been described in the next chapter. It is logical to assume that the clinical presentation (symptoms and signs) will be very similar to that of AIS, albeit in much less duration of occurrence. The pattern of presentation and duration of symptoms may be essential for prediction of recurrence, subtype and prognostication. Besides the usual and well recognized features, the unusual and uncommon symptoms have also been described.
The guidelines for the management of patients with TIA have been dealt with in great detail in the following chapter. Emphasis has been laid on the similarity in most aspects of the paradigm of management protocols of TIA and IAS, reiterating the concept of ACVS.
Radiological examination of TIA has been given an independent emphasis in the next chapter. Neuroimaging remains critical in evaluation of patients with TIA. The feasibility, cost-effectiveness, affordability, availability of CT and MRI based protocols for acute stroke multimodal imaging have been well analyzed.
Neurosonology using ultrasound and transcranial Doppler technique is fast emerging to be a prompt, bedside, neurological practice which akin to electrophysiology, has the potential to become an extension of bedside neurological examination in diagnosis, management and prognostication of stroke patients. Various established and potential applications of ultrasonography in patients with cerebrovascular ischaemia have been described in chapter 10.
Stroke subtypes and intervention studies for TIA have been enunciated in the following chapter, which essentially deals with cardioembolic source for TIAs. The last chapter expounds the available evidence and emergence of dual antiplatelet therapy for TIA patients besides describing the evolution of antiplatelet regimes from inception to newer drugs in the market. Anticoagulation for atrial fibrillation (AF) including the newer anticoagulants (NOAC) have been well analyzed. The various specific clinical aspects such as "when to switch" and "when to stop" NOAC have been dealt with.
Overall, the book has concise and succinct information narrated with clarity and conviction, and provides valuable information for neurologists, neurosurgeons and those involved in clinical research.